EMERGENCY MEDICAL TECHNICIANLisa CookstonROP Career SpecialistOrange County Emergency Medical Services

EMT Externship• Goal to understand and participate in supplementing

current EMT curriculum with new nationwide standards.

• I chose to explore Orange County’s EMT program because I work with many students who are interested in EMT and Fire service.

• I also work with Coastline Regional Occupational Program’s EMT courses scheduling EMT students for their clinical experiences.

OCEMS•Patrick Powers Paramedic BLS Program Coordinator ppowers@ochca.com 714-834-6233

OCEMS •405 w. Fifth Street Suite 301A Santa Ana, Ca 92701 714-834-3500

•Monthly Meetings April 2009-July 2009

EMT Classes•EMT classes are offered through out

Orange County through community colleges and ROP programs.

•The curriculum for these classes encompassed

12 basic life support skills. To meet Orange County Emergency Services accreditation 6 new skills were added to the EMT curriculum.

EMT Existing Skills1.  Cardiac arrest management/ AED

2.  Bag Valve Mask apenic patient

3.  Spinal immobilization supine patient

4.  Spinal immobilization seated patient

5.  Immobilization skills log bone

6.  Immobilization skills joint injury

Existing Skills continued7.  Immobilization skills traction splinting

8.  Bleeding control/shock management

9.  Airway, oxygen and ventillation skills upper airway adjuncts and suction

10.Mouth to mask with supplemental oxygen

11.Oxygen administration

12.Ventilatory management endotracheal intubation (discussed with students but did not test on this

EMT Curriculum New Skills

• MDI Assistance

• IV Set-up/Monitoring

• Endotracheal Tube and Tracheostomy Tube Suctioning

• Glucose Monitoring

• Epinephrine Auto – Injector

• 12-Lead Placement

OCEMS EMT “Accreditation” Curriculum

 

Intro to OCEMSFacilities (base stations, trauma centers, PRCs, CVRCc,

Neuro Centers, Burn, etc…)

Destination decisions (I-40 Transport Guidelines)

The 13 ALS Providers

The 1 air transport provider (Mercy Air), Orange County Fire Authority Air Rescueoccasion may be available

OCEMS approved CE providers with contact information

OCEMS approved/accredited educational programs 

EMT Scope of Practice

▫Handout of review of basic EMT State scope of practice

▫Specific Orange County EMS EMT scope of practice adds:

Glucometer

Tourniquet

Interfacility Transport

Interfacility Transport1. Intravenous: LR, TPN, < 20 mEq

KCL/1000ml, additional other basic solutions per OCEMS medical director

2. Preset self-contained medication infusion pumps for IV, SQ routes

3. Chest tubes 4. Home ventilators and home CPAP

Interfacility Transport continuedCentral Lines:• Okay to Transport: Any central vascular access line that

does not require a constant infusion to keep the line open.

• Cannot Transport: Any patient with a central vascular access line that is presently being used to monitor the patient’s condition, status, and or signs of life – requires ALS for transport.

• Cannot Transport: Any patient with an arterial line – requires ALS for transport.

Interfacility Transport Continued6. Preset enteric feeding

7. Foley Catheter

8. Gastrostomy, colostomy and urostomy

Policies and Procedures▫Provide handout of policy 300 and I-40

procedure▫Review of I-40 Procedure, specifically

transport information▫Provide handout on OCEMS BLS

treatment guidelines▫Review of OCEMS DNR policy and

California State POLST 

Skills 

• Regarding Skills Competency Testing:

▫ Skills competency checklist Each training program shall use a common OCEMS approved skill checklist Each student shall have a checklist completed for each skill that requires competency

validation▫ Skills Testing

Each training program may choose to validate skills individually or in a group setting If skills testing is performed in a group setting the proctor student ration shall not exceed 6

students for each proctor▫ Definitions:

Administer: A medication carried on a BLS ambulance (Medication brought to the scene by the EMT and stored in the ambulance)

Assist: A medication that is the patient’s own prescribed medication▫ Reinforce/review 7 patients rights of medication administration

Right Patient Right Medication Right Dosage Right Route Right Time (expiration, not exceeding maximum dose, etc…) Right Documentation Right Response (Proper reassessment and re-evaluation of patient)

CONTACT ALS and RAPID TRANSPORT (refer to I-40) for ALL of the Patients below:

▫ Use of auto-injector Epinephrine Auto-Injector

Review of Patient’s own epinephrine auto-injector▫ Medication administration technique▫ Proper disposal

Reassessment after interventions (oxygen, positioning, patient’s own epinephrine auto-injector, pulse oximetry monitoring, etc…)

Documentation of all of the above Proficient student return demonstration of administration of a

prop/trainer epinephrine auto-injector to a mock patient

Mark One® and Duodote® Auto-Injector for self administration Review of S-L-U-D-G-E-M (salivation, lacrimation, urination,

defecation, gastroinstestinal, emesis, muscle twitching) symptoms consistent with known or suspected exposure to an organophosphate

Mark One® and Duodote® Auto-Injector for self administration

2.Review of the types of antidote auto-injectors available for self administration

3.Review of technique for self administration

4.Reassessment of self looking for S-L-U-D-G-E-M symptoms or other changes to consider repeating auto-injector dose one time

5.Seek further medical care and documentation

6.Discuss limiting spread of nerve agent/organophosphate compound by speaking with public safety personnel on scene

7.Proficient return student demonstration of self administration of a prop auto-injector

Use of metered-dose-inhaler

• Albuterol or Atrovent Review of patient’s own metered-dose-inhaler

(MDI)▫Medication administration technique▫Spacers

Reassessment after interventions (oxygen, positioning, patient’s own MDI, pulse oximetry monitoring, respiratory rate, tidal volume, effort quality, etc…)

Documentation of all of the above Proficient student return demonstration of

administration of a prop metered-dose-inhaler to a mock patient

Nitroglycerine – tablet and spray

• Contraindications: Systolic blood pressure less than 90 Recent head injury Recent use of medications to treat erectile dysfunction

such as Viagra®, Levitra® or Cialis® Nitroglycerine tablets

Review of patient’s own sublingual nitroglycerine tablets Reassessment after interventions (oxygen, positioning,

patient’s own nitroglycerine, pulse oximetry, pain scale, respiratory status, etc…)

Documentation of all of the above Proficient student return demonstration of administration

of a prop sublingual nitroglycerine tablet to a mock

Nitroglycerine – tablet and spray continued

Nitroglycerine Spray Review of patient’s own sublingual

nitroglycerine spray Reassessment after interventions (oxygen,

positioning, patient’s own nitroglycerine, pulse oximetry, pain scale, respiratory status, etc…)

Documentation of all of the above Proficient student return demonstration of

administration of a prop sublingual nitroglycerine spray to a mock patient

FDA® approved oral glucose agents – gels, tablets, liquid

Contraindications: Unresponsiveness Inability to swallow or control own airway

Oral Glucose Gel, Tablets and Liquids Review of oral glucose gel, tablets and liquids and

appropriate administration techniques Reassessment after interventions (oxygen, positioning,

oral glucose gel, pulse oximetry, mental status, etc…) Documentation of all of the above Proficient student return demonstration of prop oral

glucose gel to a mock patient

12-lead placement Review of anatomical landmarks, intercostal

spaces, and midclavicular line. Demonstration of proper lead placement

using anatomical landmarks Discuss patient privacy/modesty and

appropriate lead placement and techniques on women.

Proficient return student demonstration indicating proper placement of leads on either a manikin or other appropriate model

Pulse Oximetry Use

Review of proper application and placement of probe to assure reliable readings

Treat patient’s symptoms, not the pulse oximeters reading

Documentation of pulse oximeters readings Care and maintenance of common pre-

hospital pulse oximeters per manufacturer’s recommendations

Proficient return student demonstration of pulse oximetry use and documentation on a mock

Tourniquet application Discuss and review control of hemorrhage to an extremity

Direct pressure

Demonstrate control of external hemorrhage to an extremity using an OCEMS approved tourniquet (proper placement in relation to wound and joints)

Demonstrate and discuss proper assessment of circulation, sensation and motor of the extremity before and after placement of the tourniquet and ongoing assessment

Documentation of tourniquet application

Proficient student return demonstration of application of an OCEMS approved tourniquet or simulated tourniquet to control hemorrhage to an extremity with proper assessment of circulation, sensation and motor before and after tourniquet application on a mock patient

Glucometer use

Review of aseptic technique, BSI and required equipment

Review of the steps of the procedure

Demonstration of the use of an FDA approved glucometer to obtain a fingerstick serum glucose value, including care of the wound and disposal of the sharp

Discuss and/or demonstrate the care, cleaning and routine calibration of a common FDA approved glucometer per manufacturer’s guidelines.

• Proficient student return demonstration of obtaining a fingerstick serum blood glucose value and documentation of the results on a mock patient, with proper wound care, and sharps disposal

Monitoring IV site

Reference OCEMS intravenous policy ## Review of types of IV tubing

Micro tubing Macro tubing Buretrol

Explanation of TKO (to-keep-open) or KVO (keep-vein-open) rate and how to calculate this by counting the drops per minute

Demonstrate how to prepare an IV bag and tubing for administration

Monitoring IV site continued

Discuss different types of common IV dressing and when it is appropriate to reinforce a dressing, such as when an IV site is leaking or bleeding

Discuss integrity of IV flow and common causes of occlusions

Monitoring the IV site Signs and symptoms of IV site infiltration Signs and symptoms of IV site infection

When to shut off the IV infusion by clamping the tubing and how

Discussion of types of preset infusion pumps

Student assessment▫Final written exam standardized between all

accreditation classes

10 questions maximum

Addendum

•Please see email attachments for skill sheets

Implementation

•Fall 2009 EMT are including new accredited skills curriculum.

• In the position of Career Specialist I will use

information from externship to prepare students for EMT course.• I will provide an outline of skills so

students are aware of what skills they will learn

and be certified for.

Implementation continued•In recruiting students I will share skills

that are taught in EMT course, informing them that with certification in these skills they will be prepared to test in the EMS field.

Lessons Learned & Highlights•One of the most profound lessons was how labor

intensive and time consuming it is to review, coordinate, and implement class curriculum.

•The EMT curriculum task force was made up of representatives from Saddleback College, Santa Ana College, Orange County Fire Authority, Care Ambulance, Coastline Regional Occupational Program, and Orange County Emergency Medical Services.

Lessons & Highlights continued

•Addition to the current EMT curriculum allows for standardization throughout Orange County

•A definite highlight is actually seeing the new skills taught in our current EMT classes and realizing the standard of education and medical services has improved.